How much physician guidance do patients want with medical decisions?

And rightly so. Gone are the days where medical decisions are paternalistic in nature, with the physician leading, and the patient following. Today, an ideal medical decision has input from both patient and provider.

But, have we gone too far the other way?

In a recent New York Times column, Pauline Chen asks whether doctors are yielding too much decision making authority to patients.

She cites a study showing that too much physician restraint in medical decision making may not be what patients want, and, in fact, may be unethical:

Researchers interviewed more than 8,000 hospitalized patients at the University of Chicago. When it came to medical decisions, almost all the respondents wanted their doctors to offer choices and consider their opinions. But a majority of patients — two out of three — also preferred that their doctors make the final decisions regarding their medical care.

Dr. Chen also says that the ideal medical decision should be shared in nature. Patients need to “be more explicit and ask for that help,” while doctors “will need to be more mindful of whether patients want them to share information, be directive or hand over the responsibility of the decision.”

There is a spectrum of how much physician involvement patients want. Some, like the most voracious e-patients, may want physicians to suggest and inform, but leave the ultimate decision to them. Others may prefer the old paternalistic approach, and let doctors have the final say.

The only way to know is through a continuous relationship with a single provider, so that comfort level can be developed over time. After several encounters, a clinician should have a sense of how much, or how little, direction a patient needs.

Sadly, as patients cycle through provider after provider in our increasingly fragmented health system, continuity of care is lost.

And that makes it more difficult to give patients the proper amount of guidance when making difficult medical choices.

How much physician guidance do patients want with medical decisions? 4 comments

Spot on Kevin. Reminds me of how it is when I ask my wife anything. It isn’t so much that I do as she suggests, mostly it is that I asked what she thought. Then she wants me to confidently go forth, better informed and warned of the consequences of not listening to her.

Anonymous

I consider myself an e-patient…I don’t want my doctor to just suggest and inform. I want a doctor to know me, my strengths and weaknesses, my values, hopes and dreams and make a decision that is best for me. I have a physical therapist that treats me this way…she knows function is more important than pain relief, moving is more important that being still…and makes treatment recommendations based on this. I don’t spend endless hours doing research about the best option. I trust my PT.

Perhaps doctors of a different era practice medicine in this way, but I have not met many that do now. When I walk into the doctors office, I am not a real person with real feelings. The doctor doesn’t know me because the revolving physician extenders take care of me most of the time. The care isn’t geared toward me and as a result, I don’t trust the recommendation. I don’t even need my doctor to suggest and inform. I need the doctor to order the test, do the procedure or write the prescription. The rest I have covered.

Hexanchus t

I think it depends on the patient. As you stated some want the decision to be made for them, some want to make it themselves, and some are somewhere in between. Ultimately (from a legal standpoint) it is the patient’s absolute right to decide who will make the decisions.

Regardless of the length of the physician/patient relationship the physician should never assume anything – the patient’s preferences may have changed. They should simply ask the patient what their preferences are and proceed accordingly. I don’t see what’s so difficult about that. Instead of guessing, just get it out in the open.

Personally I consider the physician as a paid professional consultant – call it a “medical engineer”. Their job/responsibility is to use their expertise to provide me with all relevant information and options and their professional recommendation – including not just “what” they recommend, but “why”. My job/responsibility is to evaluate that information in conjunction with my personal preferences and values and make the final decision on what course of action, if any, best meets those values and preferences – and to accept the responsibility for my decisions.

It isn’t just continuity of care which will help determine preference, but also situation. A very life threatening illness may make a patient more empowered or less empowered depending on the individual.

I agree, however, that MDs need to lead more, not in a paternalistic role that was more prevalent generations ago, but as a partner more often willing to make the hard call on behalf of a patient and her preferences.